(Dnro) Dh Form 1896
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1Important!
In order to be legally valid this form MUST
be printed on yellow paper prior to being
completed. EMS and medical personnel
are only required to honor the form if it is
printed on yellow paper.
This box will not show up when the form is
State of Florida
printed.
DO NOT RESUSCITATE ORDER
(please use ink)
Patient’s Full Legal Name: ________________________________________________Date:____________________
(Print or Type Name)
PATIENT’S STATEMENT
Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn.
(If not signed by patient, check applicable box):
q Surrogate
q Proxy (both as defined in Chapter 765, F.S.)
q Court appointed guardian q Durable power of attorney (pursuant to Chapter 709, F.S.)
________________________________________________________________________________________________
(Applicable Signature)
(Print or Type Name)
PHYSICIAN’S STATEMENT
I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the
patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation
(artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient
in the event of the patient’s cardiac or respiratory arrest.
________________________________________________________________________________________________
(Signature of Physician)
(Date)
Telephone Number (Emergency)
________________________________________________________________________________________________
(Print or Type Name)
(Physician’s Medical License Number)
DH Form 1896, Revised December 2002
PHYSICIAN’S STATEMENT
State of Florida
DO NOT RESUSCITATE ORDER
I, the undersigned, a physician licensed pursuant to Chapter 458
or 459, F.S., am the physician of the patient named above.
I hereby direct the withholding or withdrawing of cardiopulmonary
________________________________________________________________
resuscitation (artificial ventilation, cardiac compression,
Patient’s Full Legal Name (Print or Type)
(Date)
endotracheal intubation and defibrillation) from the patient in the
event of the patient's cardiac or respiratory arrest.
PATIENT’S STATEMENT
Based upon informed consent, I , the unders i g n e d ,h e r e by direct that CPR
be withheld or withdrawn. (If not signed by patient, check applicable box):
q Surrogate
________________________________________________________
q Proxy (both as defined in Chapter 765, F.S.)
(Signature of Physician)
(Date)
Telephone Number (Emergency)
q Court appointed guardian
q Durable power of attorney (pursuant to Chapter 709, F.S.)
________________________________________________________
(Print or Type Name)
(Physician’s Medical License Number)
________________________________________________________________
(Applicable Signature)
(Print or Type Name)
DH Form 1896,Revised December 2002
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